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Mental Status Exam Rachel Adler shadow health

outline of how to do an mental status exam on psych patients. This is...
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health promotions and education (msn590)

18 Documents
Students shared 18 documents in this course
Academic year: 2020/2021
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Tomoko Hiraoka
United States University
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Mental Status Exam (MSE) (answers in black)

Student’s Name

Shadow Health Bipolar Disorder Activity

1. Environment/Location  Location, describe milieu, include unusual circumstances (example chaotic, calm, dirty): milieu is calm, clean, and organized.  Safety (example staff present, patient belligerent or fighting, unattended “sharps”): no other staff present, patient is cooperative and nonviolent, no dangerous objects are present.  Noise level, music, background noises: Noise level is quiet, conducive to interview and minimal.  Temperature, too hot, too cold, no air conditioner: Temperature not assessed.  Colors such as bright yellow walls with pink sofa: Neutral colors and no distracting palettes. 2a. Initials, age, gender, culture  Maintain confidentiality by using initials  Age, gender, and culture are important descriptors: L. is 25 yo white American male. 2b. Reason for admission  Why was the person admitted, precipitating factors, chief complaint (in patient’s own words in quotes): “Well, this cop stopped me when I was just taking care of my business... I had a suspicion there were government agents following me... I was running around kinda...”  Under what circumstances: Baker Act, Marchman, Exparte, voluntary: “Those idiot cops brought me here. I don’t need to be here but the front desk guy said they have to check me out.” 3. History of Previous Treatment & Pertinent Family History  History of previous mental health treatment: Treated for depression starting 3 years ago after suicide attempt.  Family history of mental illness: No relevant family history of mental illness, patient is adopted as well. 4. Appearance  Appears older/younger than stated age , haggard, bewildered, exuberant: Appears older than stated age, disheveled, grimy, unkempt, and overly talkative.  Grooming: well-groomed, unkempt, clothing appropriate to season/weather, meticulous, disheveled, clothes too small/large, baggy, seductive, malodorous, feces/urine noted, unusual hair color, matted hair: patient is not well-groomed, unkempt, disheveled, clothes are grimy.  Skin: lesions, tattoos, piercings, scars, bruises, cutting, excessive make-up, bizarre color of makeup: Scars bilaterally on both wrists, fresh scratched on upper back bilaterally.  Weight: underweight, emaciated, thin, normal weight, overweight, obese: not able to assess weight, but patient looks thin, calls himself a “string bean supermodel”  Stature and Gait: tall, shuffling, rigid, stooped, bizarre posturing, avoids stepping on lines on floor: not able to assess gait.  Eye contact: avoidant, fleeting, stares at ___, eyes closed, blank stare, anxious, tearful: Direct eye contact.

5. Behavior  Attitude towards examiner: cooperative, friendly, hostile, defensive, guarded, apathetic, evasive, argumentative, manipulative, irritable, disinterested, overly sensitive, combative, drug seeking: Cooperative, but wary, willing to answer some questions but strongly avoids others, evasive.  Mannerisms, tics, gestures, stereotyped behaviors, hyperactive, agitated, restless, psychomotor agitation/retardation, combative, impulsive, ritualistic, easily distracted, dis-inhibited, dependent, sarcastic, threatening, violent, manipulative, suspicious, passive, silly, demanding, in contact with

reality, attention seeking, labile, fearful, euphoric: fidgety, constant gestures, hyperactive, hyperverbal, agitates, restless, dis-inhibited, sarcastic, euphoric. 6a. Level of consciousness  Alert, clouding, stupor, coma, lethargy: AAOx 6b. Cognitive attributes  Orientation to person, place, time, and situation: AAOx  Memory: long term (remote past experiences), recent (within the last two weeks): long term and short term memory intact with testing.  Level or fund of knowledge: spell the word “world” backwards, discuss current events, vocabulary, education level: Vocabulary is broad, education level is 1 year of college before getting expelled for not attending classes due to depression.  Ability for calculation: serial 7’s and is too difficult, use serial 3’s: Seral sevens successful  Abstract versus Concrete Thinking: interpret the phrase “the grass is always greener on the other side”, “people in glass houses should not throw stones”, “a stitch in time saves nine”, “don’t cry over spilled milk”: Abstract thinking intact for questions like “how are an apple and orange similar?”  Insight: self-understanding, how the patient understands what is happening, denial of illness, level of awareness of illness: denial of illness; unaware of current disease state, is reveling in increased energy.  Judgment: Does the patient understand the outcomes of a particular behavior? Assess throughout the MSE: Patient appears to have good judgement when asked about what to do with a stamped envelop on the ground (answer: put in a nearby mailbox), however patient expresses lack of foresight and judgment throughout the interview by not going to sleep, refusing to eat, and demonstrating erratic behavior in the parking lot. 7a. Thought process  flight of ideas  tangential  neologisms  echolalia 7b. Thought content  Delusions: patient is convinced that government agents are after him 8a. Mood (inner feelings that must be addressed)  Euphoric, expansive 8b. Affect (outward display of feelings)  Bright  Are mood and affect congruous or incongruous? Mood and affect are congruous. 9. Speech  excessive, pressured, talkative, irrelevant, constant flow, gregarious, sarcastic

10a. Suicidal/homicidal ideation—This must be addressed and documented!!

Always assess for: ideation, plan, means and intent. Is there a history of suicide attempts or self harm. Assess for homicidal ideation, plan, means and intent. What are your responsibilities in reporting the situation (Tarasoff Act)? No current suicidal ideation, no means, no intent. History of suicide attempt 3 years ago and was hospitalized. No intent to harm himself or others.

10b. Interpersonal Violence

 Does the person feel safe at home, is there a history of abuse in the home? No history of abuse, but patient lives in his car or with friends, and feels safe there.

10c. Potential for violence—This must be addressed and documented!!

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Mental Status Exam Rachel Adler shadow health

Course: health promotions and education (msn590)

18 Documents
Students shared 18 documents in this course

University: United States University

Was this document helpful?
Mental Status Exam (MSE) (answers in black)
Student’s Name
Shadow Health Bipolar Disorder Activity
1. Environment/Location
Location, describe milieu, include unusual circumstances (example chaotic, calm, dirty): milieu is calm,
clean, and organized.
Safety (example staff present, patient belligerent or fighting, unattended “sharps”): no other staff
present, patient is cooperative and nonviolent, no dangerous objects are present.
Noise level, music, background noises: Noise level is quiet, conducive to interview and minimal.
Temperature, too hot, too cold, no air conditioner: Temperature not assessed.
Colors such as bright yellow walls with pink sofa: Neutral colors and no distracting palettes.
2a. Initials, age, gender, culture
Maintain confidentiality by using initials
Age, gender, and culture are important descriptors: L.C. is 25 yo white American male.
2b. Reason for admission
Why was the person admitted, precipitating factors, chief complaint (in patient’s own words in quotes):
“Well, this cop stopped me when I was just taking care of my business… I had a suspicion there were
government agents following me… I was running around kinda...”
Under what circumstances: Baker Act, Marchman, Exparte, voluntary: “Those idiot cops brought me
here. I don’t need to be here but the front desk guy said they have to check me out.”
3. History of Previous Treatment & Pertinent Family History
History of previous mental health treatment: Treated for depression starting 3 years ago after suicide
attempt.
Family history of mental illness: No relevant family history of mental illness, patient is adopted as well.
4. Appearance
Appears older/younger than stated age , haggard, bewildered, exuberant: Appears older than stated
age, disheveled, grimy, unkempt, and overly talkative.
Grooming: well-groomed, unkempt, clothing appropriate to season/weather, meticulous, disheveled,
clothes too small/large, baggy, seductive, malodorous, feces/urine noted, unusual hair color, matted
hair: patient is not well-groomed, unkempt, disheveled, clothes are grimy.
Skin: lesions, tattoos, piercings, scars, bruises, cutting, excessive make-up, bizarre color of makeup:
Scars bilaterally on both wrists, fresh scratched on upper back bilaterally.
Weight: underweight, emaciated, thin, normal weight, overweight, obese: not able to assess weight,
but patient looks thin, calls himself a “string bean supermodel”
Stature and Gait: tall, shuffling, rigid, stooped, bizarre posturing, avoids stepping on lines on floor: not
able to assess gait.
Eye contact: avoidant, fleeting, stares at ___, eyes closed, blank stare, anxious, tearful: Direct eye
contact.
5. Behavior
Attitude towards examiner: cooperative, friendly, hostile, defensive, guarded, apathetic, evasive,
argumentative, manipulative, irritable, disinterested, overly sensitive, combative, drug seeking:
Cooperative, but wary, willing to answer some questions but strongly avoids others, evasive.
Mannerisms, tics, gestures, stereotyped behaviors, hyperactive, agitated, restless, psychomotor
agitation/retardation, combative, impulsive, ritualistic, easily distracted, dis-inhibited, dependent,
sarcastic, threatening, violent, manipulative, suspicious, passive, silly, demanding, in contact with

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